Many small children do not receive proper dental care or, indeed,
any dental care. Dental care for children should be of great
interest to the population at large, as untreated dental caries in
preschool can create further, more expensive to repair dental
deficiencies, as well as health hazards due to untreated caries.
Those adults with a history of poor dental care risk losing teeth at
an early age, thereby compromising their nutritional status.
Dental caries can also be a source of infection and place the
person at risk for the spread of infection to other organs. A review
of the relevant literature allows us to identify through current
research the causes of poor dental care among children and what
treatments have been studied to enhance dental care for children.
Despite a lack of dental treatment for small children, there is
overall widespread concern, as well as many published attempts to
identify psychological causes and find solutions which will ensure
appropriate dental treatment at an early age. The concern is global.
For example, besides the United States, research has been conducted
in the Netherlands (Weerheijm et al, 1999), Poland (Ilieva, 1999),
Canada (Haas et al, 1996), Finland, Israel (Peretz & Gluck, 1998),
Great Britain (Hosey & Blinkhorn, 1995), Japan (Mitome et al, 1997),
Turkey (Akyuz et al, 1996), Spain (Boj & Davila, 1995), France
(Rousset et al, 1997) and Sweden (Klingberg et al, 1995).
In the United States many books have been written for children in
order to promote early dental hygiene through early education by
alleviating fears. Interaction between parent and child through
these books may alleviate fear passed from parent to child. Newman
(1997) states, “adults, particularly parents, should serve as role
models for their children.” Several articles imply that good
parenting and education can stop dental fear and promote dental
compliance.
Price and Vaughn (1999) studied child care centers as a source of
good dental care promotion through educational workshops conducted
for staff. Their conclusion was the staff could make significant
inroads into good dental health through continuous dental health
programs and educational workshops.
Other pertinent literature has identified solutions for children’s
anxiety and fear of the dentist. Nathan (1995) designates behavior
management with strategies to enhance self esteem and foster a
positive attitude as the best way to persuade the child to accept
care.
Some countries have established special clinics to study the cause
of dental fear in children and methods to treat the fear and to
promote adequate treatment. In the Netherlands, ten Berge et al,
(1999) conducted studies at a special dental care clinic established
for children who have very high levels of fear, and also to study
their behavior. It was found that children with extremely high
dental fears also have other behavioral and emotional problems.
Those with developmental delays, as well as behavioral and emotional
problems, are among the populations studied with the greatest lack
of dental compliance.
In Sweden, those children with severe dental fear and avoidance of
treatment are referred to the Dental Fear Clinic in Gothenburg.
Besides the high frequency of missed or cancelled appointments,
studies there indicate other problem behaviors in many of the
children identified with dental fear, as well as a relationship
between dental fear in parents and children (Klingberg et al, 1992).
Due to widespread interest in the causes of dental fear, many
instruments have been developed to use in research studies. A well
known and often used instrument for assessing dental fear with
acceptable reliability and validity is the Children’s Fear Survey
Schedule (CFSS-DS). The Dutch and Finns have used this instrument
and found the single most common fear is related to invasive
treatment aspects ten Bergs et al, 1998).
A study by Hosey and Blinkhorn (1995) evaluates four instruments to
assess the behavior of anxious child dental patients in order to
accurately study dental fear. The scales were used to assess anxious
children during dental treatment. They are the Frankl, Houpt, Visual
Analogue, and Global Rating scales. An interdisciplinary team, two
authorities in the management of anxious children and four dentists,
evaluated the scales. While close argument was found on the Visual
Analogues and Houpt scales, it was not so with the Frankl scale. The
Global rating Scale indicated significant correlation between it and
the other three scales. It is obvious from the plethora of
instruments to study psychological causes of fear that the
conventional wisdom leans in the direction of fear as a major cause
of dental anxiety and poor compliance. It is certainly the most
studied aspect.
Studies involving drugs such as midazolam for conscious sedation
have not clearly given us answers to drug therapy for anxious
children (Hass et al, 1996) and its use in promoting good dental
hygiene. In Israel, Peretz and Gluck (1998) profess that nitrous
oxide benefits are overwhelmed by subsequent visits and fear
rendering the drug unhelpful to control fear and increase
compliance. Reinemer, Wilson and Webb (1996) conducted studies
measuring psychological and behavioral aspects of fearful patients
following 4 mg. and 8 mg. ketamine-diazepam administration prior to
dental procedures. While the larger dose was more efficacious, it is
unclear whether the overall benefit was worth the risk to the
patients.
Yasane et al, (1996) studied the effects of home administered oral
diazepam prior to dental treatment. The authors concluded the 0.3
mg/kg dosage was safe and an effective treatment for children of
approximately three years and eight months. Lu et al (1994) used a
retrospective study to evaluate the efficacy of IM injections with
ketamine, meperidine/promethazine, and midazolam. The results
indicated a good safety and efficacy rating from clinicians and
patients for controlling fears.
In 1996, a study by Haas et al, reviewed the use of chloral
hydrate, a long used drug, and the newer drug midazolam. Neither was
superior for controlling dental fear and the authors called for
further studies. Conversely, Duncan et al (1994) touts chloral
hydrate as the ideal drug for safety and effectiveness.
Many more efficacy studies in relation to age and level of fear are
needed in order to identify those drugs which most successfully
control fears. Many are established as safe, but the evidence for
efficacy is scattered, unorganized and inconclusive. General
anesthesia, while efficacious, is considered as a last resort for
treatment due to safety concerns (Seheult et al, 1993).
Very little of the relevant literature on the subject is directed
at combination therapy. Lu (1994) promotes the use of hypnotherapy
and ketamine. Lu found this combination successful, but it must be
noted the population was one with a history of violent reactions to
dental treatment and may not be meant for all. Future studies of
combination therapies, drugs and psychological treatments, could
illuminate useful therapies.
While it is interesting to note that fear is often studied as the
major cause of poor dental treatment among children, other important
causative factors need further research. Economic status and access
to affordable delivery care systems as such factors have not been
adequately studied and researched. It is much easier to identify a
solution to a child’s fears than it is to solve the economic
problems of a whole society or culture. Studying dental fear in
children is easily applied to modern psychological theory, while
correcting the economic inadequacies of a culture, and the effect of
it on dental care in children, is not easily, lightly, or often
undertaken.
The identification of other causative factors besides fear could
promote comprehensive dental treatment and management. Methods of
dental care delivery for those who are economically challenged have
uncovered a population, not fearful, but lacking in resources.
Transportation, money to pay fees, and distance may be constraints
on the poor, which if solved could promote better dental care. Other
characteristics of poor, transient populations, such as frequently
changing addresses, telephone numbers, and employers, as well as
changing insurance and coverage, contribute to poor dental health.
Non-psychological causes of non-compliance with dental care regimes
have identified all the same problems which plague the poor, i.e.
lack of ability to pay, transportation to adequate care sites and
the general unstable lifestyle which often accompanies poverty.
Those same delivery system problems which make adequate general
medical care prohibitive for the poor also have an impact on dental
care.
Studies reveal there are two major areas, psychological and
economic, which cause poor dental care. Psychological causes of poor
dental care among children include the fear and anxiety which lead
to noncompliance. The most prevalent fear is of “invasive
treatments”. Populations at high risk include those with
developmental delays, behavioral and emotional problems (ten Bergs
et al, 1999). Klingberg and Berggen (1992) have studied the
relationship between dental fears in parents and children. If the
parent is frightened and noncompliant, so it follows, the child will
be the same.
After reviewing the compilation of material on children and dental
care, it is clear the answer to improved pediatric dentistry lies
within an interdisciplinary and holistic approach. Individuals must
be viewed as such, and appropriate solutions for each individual
implemented, be they psychological, economic or social. A thorough
assessment by the health care provider will indicate if the source
of the problem is psychological, economic, or a combination of both.
Treatments by the appropriate discipline will result in enhanced
compliance with dental appointments, regimes and treatments.
Behavior management, education, “good parenting”, role models,
drugs, general anesthesia and hypnotherapy are have all been
identified as possible ways to improve dental care for small
children by controlling fear.
A combination approach to treatment may be more successful for many
as the cause of their dental dilemma may be both psychological and
socio-economic. A wise clinician may use behavior modification,
drugs and education in order to promote the best outcomes. The
relevant literature suggests that family practice settings may well
be helpful to initially identify problems and coordinate solutions.
Pediatric dentists, who bring special expertise to this area, are
not prevalent enough to solve the problem of inadequate dental care
among children.
Future studies may best be managed by interdisciplinary teams which
cover all the aspects, psychological, economic and sociological.
Certainly, there is a need for more studies to evaluate the best
approaches to solving the problem. Varpio and Wellfelt (1991)
studied children referred to a pedodontic clinic and acceptance
outcomes for dentistry over five years. A positive attitude was
fostered through the use of a special clinic. The results indicated
the high rate of acceptance of dental care by the children over time
was due to the early intervention. Hypnotherapy was the only
treatment which came close to an alternative medical approach
identified in the literature for dental concerns.
On a larger scale, economic solutions may be implemented to aid
groups of individuals who are at risk or already lacking in dental
services. The focus of these dental solutions will be based on the
concept of persons belonging to a group and in need as part of a
subculture. Social programs may target children, persons with
incomes below a certain level, geographic location, and access to
services or special needs populations such as those with
developmental delays.
Brown et al (2000) point to a decline in untreated children, which
is a positive sign for improved dental health. Improved methods for
preventing dental caries such as fluoridated water, dental sealants
and early intervention are resulting in generation of children who
do not suffer with caries as children have in the past. It is
projected that many will enjoy a level of dental health in the
future that has not been known in the contemporary world.
As usual, the answer to a large widespread problem is never simple
and direct. Pediatric dentists in combination with specialists in
psychology can be invaluable in promoting the best therapies for
fearful patients. Socially speaking, the legislator may provide the
best relief for economic concerns. Social change can be influenced
by those who take the time to study the issues and bring it to the
attention of those in a position to implement such change.
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